Graeme Hall BSc Dip Clin Pharm MRPharmS
Deputy Chief Pharmacist
I read with much interest the above Opinion piece on optimisation. A paper published by researchers from Northern Ireland in 2012 on the introduction of medicine lockers is referenced, which found that the use of one-stop dispensing (OSD) and bedside lockers, decreased drug round times and reduced error rates. These results are contrary to our observations and reports at the University Hospitals of Leicester (UHL) that we referred to previously. Our findings are supported by work carried out recently by researchers at Imperial Hospital where they found drug round times increased with multiple stocking locations and reported nurses frequently needing to check three places before finding the required medicine.1
It is suggested that the negative experience with OSD was an issue about implementation strategy rather than the process itself. We believe the picture is more complicated than just implementation, The size, complexity and throughput of patients may well be a factor in determining whether OSD will work or not. Levels of pharmacy staff are also undoubtedly a factor. The recent NHS England benchmarking exercise shows that there are large variations with pharmacy staffing levels across English hospitals. One thing is certain: for both financial and skilled staff availability, the number of staff is very unlikely to increase in the future.
It is fair to say that the profession accepts that medicines use is suboptimal. Within the context of the guidelines and objectives deriving from the Medicines Optimisation programme, UHL asked itself whether it was doing enough to achieve optimal outcomes, quality and value. We decided that a technological and logistical solution using software, robotics and automation should be considered, and, if appropriate, piloted.
The fact that medicines are dispensed and then destroyed as the purchase price is low is an argument that is made. In addition to the natural unease arising from this argument, there is another cost which has to be factored in, that of the professional time it takes to dispense then return and dispose of them, time that could be utilised in other ways. In the system we are testing, the dispensing workload is reduced dramatically with inpatient supplies packed robotically, and ‘top up’ of cabinets being driven by actual usage of the medicines. The cabinets are filled ‘predictively’ as the software calculates future usage based on historical administration. This also minimises ward stock levels to reflect the actual usage, rather than the perceived demand.
It is a fair and pertinent point that inhalers, creams and liquids cannot be unit dosed; however, the software logistically controls non-unit dosed lines in addition to unit dose, automating top up and continuously recalculating stock levels required. In Italy, 85% of typical hospital pharmacy stock items have the ability to be unit dosed, including syringes, ampoules, sachets, as well as solid oral dose forms. So far, the UHL Pilot is converting some 80% of ward medicines into unit doses.
The individual supply items such as creams and inhalers will need to move with the patient but these are a tiny fraction of the current level of medicines ‘lost between wards’.
In conclusion we believe that the article raises valid issues with regard to the OSD system encountered in some hospitals. We believe however, that these could be explained by activity and staffing levels, as well as implementation strategies. The logistical, quality, safety and financial benefits of what we are doing appear to have been underestimated. The evidence will be in the analysis of results from the pilot by researchers at Loughborough University and we all await this with interest.
- McLeod M. Medication administration processes and systems – exploring the effects of systems-based variation on the safety of medication administration in the UK National Health Service [PhD thesis]. London: University College London, The School of Pharmacy; 2013.